• 
• 

Three Part Question

Is [bedside USG] in ED [highly sensitive and specific] to [diagnose pulmonary edema]?

Clinical Scenario

65 yrs old gentleman comes with SOB for last 12 hrs, has got previous history of COPD and IHD, would Ultrasound be helpful to differentiate between Pulmonary edema and COPD?

Search Strategy

Embase, 1980- june 2011
Medline, 1950- june 2011
Cinhal, 1981- june 2011
Google


(ultrasound AND pulmonary AND edema).ti,ab

Search Outcome

We had 281 hits and 5 papers were found to be relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
E Agricola et al, Italy May 2005 Italy	20 pts , post cardiac surgery	Prospective, observational, single center study.	The presence and the number of comet-tail images provide reliable information on interstitial pulmonary edema.	A significant positive linear correlation was found between echo comet score and radiologic score (r = 0.60, p < 0.0001), and no significant difference in the mean difference between these two scores was observed (bias, 4.7; 95% limits of agreement, − 9.9 to 19.3).	Single center, Small number, Selection bias, Training issues.
D Lichtenstein et al 1997 France	250 pts at Intensive care unit	Prospective, Observational study	Analysis of the comet-tail artifact allowed us to detect alveolar-interstitial syndromes, at the bedside	USG has 92.5% sensitivity and 65.1% specificity in diagnosing alveolar-interstitial syndrome	Single center, Small number, Selection bias.
R Coppeti et al 2008 Italy	58 consecutive pts admitted to ICU with ARDS, Pulmonary Edema	Prospective, Observational	In the critically ill the ultrasound demonstration of a dyshomogeneous AIS with spared areas, pleural line modifications and lung consolidations is strongly predictive, in an early phase, of non-cardiogenic pulmonary edema.	AIS was found in 100% of patients with ALI/ARDS and in 100% of patients with APE ). A pleural effusion was present in 66.6% of patients with ALI/ARDS and in 95% of patients with APE (p < 0.004). 'Lung pulse' was observed in 50% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001).	Single center, Small number, Selection bias, No training details. No power calculation
G Volpicelli et al 2008 Italy	Usefulness of bedside US in diagnostic distinction between different causes of dyspnea.	Review article	Bedside USS is a non ionizing, immediately implemented, highly feasible and time saving technique for differentiating between COPD and pulmonary edema.	>3 comet tail artefacts/ screen are diagnostic of Pulmonary edema.	No statistical significance, no clear objectives, no power calculation.
P M Zechner et al 2009 Austria	2 pts with COPD and IHD.	Case report	Pre hospital USG helped differentiating between Pulmonary edema and COPD.	Bedside USG is a useful technique for differentiating between Pulmonary edema and COPD and can lead us to right treatment.	Case report, no statistical significance.

Comment(s)

The level of evidence available is 3 and 4 but it still signifies the role of US to to differentiate between Pulmonary edema and COPD.We do need a multicenter, randomised trial to make a stronger case.

Clinical Bottom Line

The available evidence does show that bedside ED USG is highly valuable to diagnose pulmonary edema in acutely unwell patients.

References

1. E Agricola et al Ultrasound Comet-Tail Images”: A Marker Of PulmonaryEdema chest May 2005
2. D Lichtenstein et al , A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD Am J Respir Crit Care Med 1997
3. R Coppeti et al Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome Cardiovascular Ultrasound 2008 2008
4. G Volpicelli et al Bedside Ultrasound of the lung for the monitoring of acute decompensated heart failure AJ Emergency medicine 2008
5. P M Zechner et al Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of COPD AJ Emergency medicine 2009